Demolition Permit Application Form
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1
2DEMOLITION PERMIT APPLICATION
NON-REFUNDABLE APPLICATION FEES DUE AT TIME OF SUBMITTAL / APPLICATIONS IN PENCIL WILL NOT BE ACCEPTED
Effective FBC 5th Edition 2014
EFFECTIVE CODE IS 2010 FBC
: RESIDENTIAL______
COMMERCIAL______
CHECK ONE
RSN #_______________________
REFERENCE #______________________________________________
Property Information
Tax Parcel Number (Short) ___________-_________-_________-____________ Long Parcel Number ________________________________________
Owner/Leaseholder’s Name___________________________________________________________ Day Phone #: ______________________________
Address
Cell Phone #
_________________________________________________________________________________
: ____________________________________
City
Fax #:
________________________________________________________ State____________ Zip_______________
_____________________________________
E-Mail Address____________________________________________________________________________________________
Fee Simple Titleholder
Address
__________________________________________________
_______________________________________________
(If other than owner)
City
State
Zip
___________________________________________________________________
________________________
_____________________
__________________________________________________________________________________________________
JOB SITE ADDRESS:
City
County
Zip
__________________________________________________________________________________
_____________________
_____________________
Frame
Concrete Block
Steel
Other________________________________
TYPE OF BUILDING OR STRUCTURE TO BE DEMOLISHED:
No. of Buildings/Structures_____________
No. of Stories_________
No. of Units___________
Value of Work:$__________________________.00
Previous use of Building(s)_______________________________________________ Impervious Area Remaining (sq ft) ___________________________
Proposed use of site
Date to be developed__________________________
______________________________________________________________________
Asbestos Notification Statement: Refer to Florida Statutes 469 which provides licensing, training and surveying requirements for asbestos abatement.
Please contact the Florida Department of Environmental Protection at 407-893- 3333 for information on Chapter 62-297 F.A.C. which provides requirements
for demolition and asbestos renovation.
CONTRACTOR
CHECK HERE IF OWNER CONTRACTOR ON OWNER’S PROPERTY FOR OWN USE________
Name of License Holder
License #
_________________________________________________________________
__________________________________________
Company Name
Phone #:
___________________________________________________________________________________
_________________________________
Address
Mobile #:
__________________________________________________________________________________________
_________________________________
E-Mail Address for business use
_____________________________________________________________________Fax #: ___________________________________
DEMOLITION CONTRACTOR (If applicable) : Card Holder’s Name____________________________________ License #___________________________
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of
a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. OWNER’S AFFIDAVIT: I certify that all the
foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. ** I hereby declare that all
information contained in this building permit application is true and correct**
Signature of Applicant__________________________________________________________________ Date_______________________
Check one: ____ Owner/Builder
Contractor or Authorized Agent
(Must personally appear in office & sign) _____
(Agent must submit site specific agent letter)
STATE OF FLORIDA
COUNTY OF_
_________________________________
Affirmed and subscribed before me this
___________
day of
____________ 20______ by_________________________________________________________________
Personally known______ or Produced Identification_______
Type of Identification Produced___________________________________
______________________________________________________________
Signature of Notary Public State of Florida
Seal:
______________________________________________________________
Print, Type or Stamp Name of Notary
**Worksheet on back must be filled out completely**
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